Provider Demographics
NPI:1639414469
Name:KELLOGG, CHRISTINE M (PTA)
Entity Type:Individual
Prefix:MRS
First Name:CHRISTINE
Middle Name:M
Last Name:KELLOGG
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 DODGE ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02907-2210
Mailing Address - Country:US
Mailing Address - Phone:401-521-9600
Mailing Address - Fax:
Practice Address - Street 1:135 DODGE ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02907-2210
Practice Address - Country:US
Practice Address - Phone:401-521-9600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-05
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPTA00554225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant